Virginia Iglesias-Sierra

Background: The ageing of the population and the progressive increase in chronic diseases represent a major challenge for healthcare systems. The community nurse case manager (CNCM) is emerging as a key figure to provide comprehensive and continued care for complex and pluripathological chronic patients (CPCPs), especially after hospital discharge. Objective: The aim of this study is to pilot CNCMs in assisting CPCPs and assess their effects on functional capacity, cognitive performance, quality of life, readmissions, clinical parameters, satisfaction with home care, and caregiver overload. Methods: A comparative study will be carried out at two health centres in Salamanca (Spain). In both centres, CPCPs will continue to receive the interventions included in the Castilla y León Health System Portfolio from their primary care (PC) nurses. In the intervention centre, case management provided by a CNCM will be added. We will recruit 212 CPCPs with cardiac or respiratory disease and/or diabetes mellitus who are dependent for basic activities of daily living and have a programmed hospital discharge. An initial assessment will be performed at home after discharge, followed by assessments at 3, 6, and 12 months. Expected results: The intervention is anticipated to improve all study outcomes. Discussion: CNCMs may contribute to more proactive and individualised follow-up care for CPCPs and their caregivers, improving care coordination. Conclusions: This study will help to evaluate the feasibility and clinical relevance of incorporating the CNCM’s role into PC. This study was registered at ClinicalTrials.gov with the identifier NCT06155591. The date of trial registration was 24 November 2023.